Management of alcohol dependence in primary care

Alcohol has a particular place in Irish culture. As a nation we drink far in excess of most of our European counterparts. In a survey carried out in 2003, Ireland ranked third behind Hungary and Luxembourg for drinking most alcohol among a group of 26 countries. The writer and journalist John Waters once wrote: “Drinking in Ireland is not simply a convivial pastime, it is a ritualistic alternative to real life, a spiritual placebo, a fumble for eternity, a longing for heaven, a thirst for return to the embrace of the Almighty.” 

Ireland may well rank high up in the international league table of drinkers but it is estimated that only about 10% of those who drink excessively actually present for formal treatment. There are a number of reasons why this figure is so low including stigma, fears around anonymity, poor insight and lack of faith in current treatment options. Any sensible national policy around alcohol needs to address the issue of treatment, which has been under resourced for many years.

Approaching the problem in general practice

Family doctors are in a unique position when it comes to treating patients. They often know their patients and families well, and a bond of trust has developed over many years. Screening for alcohol problems should be relatively simple and yet far too few established alcohol problems are picked up in general practice. There are many possible reasons for this. Problem drinking often has an insidious onset and its clinical signs may not be obvious. A routine trip to the GP with alcohol-related symptoms such as depression or heartburn may not yield the likely cause unless questions around alcohol use are addressed. 

Brief interventions are a simple and cost effective early intervention, and are successful in one in 10 drinkers without the need for more formal treatment. A brief intervention is defined as any therapeutic intervention of short duration (one to five sessions) designed to influence patients to think more proactively about their alcohol consumption. 

Despite their relative effectiveness, brief interventions are not widely used in general practice. There are a number of brief screening tools which are simple to carry out. These include the CAGE and AUDIT questionnaires, with which many GPs will be familiar. Routine questions about alcohol intake should be asked with the specific intention of ruling in or ruling out a problem, and the way in which the GP couches the question is as important as the question itself.  For example, a far more effective question than ‘do you take a drink?’ might be ‘do you drink often?’

If the patient responds that they do drink often then you might ask them how often and do they ever ‘overdo it’? This is important because it can guide the GP to the context and extent of the patient’s drinking in an less intrusive way. It is then easier to piece together the physical symptoms with the level of drinking and this will reduce the stigma the patient may feel in being quizzed on a sensitive issue.

Classification of alcohol dependence syndrome

Alcohol dependence syndrome (ADS) is defined by The World Health Organization’s ICD-10 as “a cluster of physiological, behavioural and cognitive phenomena in which the use of alcohol takes on a much higher priority for a given individual than other behaviours that once had greater value. A central descriptive characteristic of the dependence syndrome is the desire (often strong, sometimes overpowering) to take alcohol. There may be evidence that return to alcohol use after a period of abstinence leads to a more rapid reappearance of other features of the syndrome than occurs with non-dependent individuals”.

A definite diagnosis of dependence should usually be made only if three or more of the following have been experienced or exhibited at some time during the previous year: 

• A strong desire or sense of compulsion to take alcohol
• Difficulties in controlling alcohol-taking behaviour in terms of its onset, termination or levels of use
• A physiological withdrawal state when alcohol use has ceased or been reduced, as evidenced by – the characteristic withdrawal syndrome for alcohol; or use of the alcohol with the intention of relieving or avoiding withdrawal symptoms 
• Evidence of tolerance, such that increased doses of alcohol are required in order to achieve effects originally produced by lower doses 
• Progressive neglect of alternative pleasures or interests because of alcohol use, increased amount of time necessary to obtain or take alcohol or to recover from its effects 
• Persisting with alcohol use despite clear evidence of overtly harmful consequences.

The severity of alcohol dependence questionnaire (SAD-Q) is a very useful way of measuring dependence by asking multiple choice questions on symptoms primarily related to withdrawal. Each answer is weighted according to a Likert-type scale ranging from a zero score for an ‘almost never’ to a three for ‘nearly always’, with a range of other options in between. The score can then be measured according to the following ranges:

• A score of 31 or higher indicates ‘severe alcohol dependence’
• A score of 16-30 indicates ‘moderate dependence’
• A score of below 16 usually indicates ‘mild physical dependency’.

The SAD-Q can be quite useful in guiding the clinician to the extent of an alcohol problem but should be used in conjunction with other assessment and screening tools and, most importantly, clinical judgement. 

There are other areas of the assessment and history that are important and relevant to alcohol dependence. As GPs will know many of the patients they treat very well, they will often have detailed information about them already on file. With increasing constraints being placed on GPs, the time spent with a patient struggling with alcohol needs to be targeted, efficient and goal-orientated. If a GP feels that the level of severity and complexities of the case are beyond his or her level of expertise, then they should refer to a specialist who can provide the appropriate advice and care.

Unfortunately, many GPs do not have a readily available pathway of referral that will meet the needs of every patient. There are a number of barriers to referral including cost, setting (eg. inpatient versus outpatient), the treatment philosophy of specialist centres (eg. abstinence versus harm reduction) and levels of patient motivation. Often the GP is left in a position where they treat the problem with inadequate or absent resources. This is a very difficult and tricky position for the GP who has the ultimate responsibility of providing care. There is no doubt that more money and resources are needed to support community alcohol treatment than are currently provided. There should also be a facility for GPs to talk to specialists in drug and alcohol treatment services should the need arise. Education is important and there are many courses provided by the various colleges (ICGP, CPsychI) that can provide GPs with better skills in approaching patients misusing alcohol.

The mildly alcohol dependent patient

Often patients who are misusing alcohol at the mild end of the scale are missed as the problem may not seem obvious or the presentation is unrelated to their use of alcohol. Again, a few routine but targeted queries can provide the GP with useful information and little more than a brief intervention may be enough to make patients more mindful about their drinking, particularly if their alcohol use is in some way related to their presenting symptoms. Written information in the form of leaflets or online links can reinforce the importance for patients of being more aware of the negative impact that alcohol can have on their mental and physical health. Formal treatment is often not required for mild cases but any patient expressing a wish for specialist help should be referred appropriately.

The moderately alcohol dependent patient

The greater the severity of an alcohol problem, the less effective brief interventions tend to be and a more intensive approach is often required. This is not to say that brief interventions should be abandoned as they can be an important screening tool for all types of alcohol dependence. Like mild cases, moderate alcohol abuse is often not directly picked up in general practice. Patients will present with other problems and if they want to conceal the extent of their drinking they will do so without too much difficulty, even when faced with abnormal liver function tests or physical signs suggestive of over-drinking (eg. alcohol fetor, hypertension, depression or features of alcohol withdrawal). It is the skill of the GP, in tying together the signs and symptoms of alcohol misuse, that will be a crucial determinant in preventing such a patient from ‘slipping through the net’. A sensitive approach is important as patients tend to respond poorly when the advice is dictatorial. 

The following example illustrates effective responses to queries about depressive symptoms:

GP: “When do you feel most depressed?”

Patient: “In the morning doctor.”

GP: “Would this be every morning or would it be worse at any particular time? I’m talking about stresses, worries or perhaps after taking alcohol.”

Patient: “Yes, I feel really down after I have been drinking the night before.”

GP: “Would this happen often?”

Patient: “Recently, yes. I have been drinking a lot more than normal.”

This has led the GP to an important component, if not the cause, of this patient’s problem. The doctor has tread carefully and established that the patient is becoming more dependent on alcohol. This has been a crucial intervention because the GP can now offer the appropriate advice having established the role of alcohol in the context of the patient’s depressive symptoms. This also helps to reduce the stigma to the patient and enhances the therapeutic alliance – key features of an effective outcome.

Best treatment approach

Having established the problem, the next step for the GP is deciding what is the best treatment approach that will meet the needs of the patient? Treatment should always be individualised and take into account other issues such as psychiatric history, social circumstances, employment, confidentiality and family support. For example, there is little point in referring a working father of three children to an inpatient facility that he is reluctant to attend or if he cannot take time off work. Equally, it will be difficult to treat a patient with complex medical and psychiatric needs who is drinking heavily in the community, and the best option may be inpatient detoxification, even for a short period of time until their condition has stabilised.

Regardless of the setting there are a number of important evidence-based treatment interventions. GPs need to first decide whether they have the expertise and resources to treat the problem. With moderately severe alcohol dependence it is likely that the patient will need to be referred and may need detoxification with chlordiazepoxide. This is to help with alcohol withdrawal symptoms and the dose of the drug is reduced gradually to zero over five to seven days, when the worst symptoms of alcohol withdrawal will have abated. Following this, there are a number of ‘talking therapies’ that are effective in reducing the risk of relapse. These include cognitive behavioural therapy, motivational interviewing, supportive counselling and family therapy. Patients may or may not wish to engage in group sessions and their wishes should be respected.

Abstinence versus sensible drinking

This is an interesting debate that has raged for decades and has polarised therapists working in the field. The question arises: can patients who drink too much change their drinking pattern and adopt a more sensible relationship with alcohol? The research would tend to support controlled drinking for most users with mild and moderate alcohol dependence, but the message tends to be lost on those patients with a pervasive and severe relationship with alcohol. It should also be remembered that alcohol dependence is often a continuum whereby users can go through different patterns of use, ranging from abstinence to controlled drinking to dependence. 

The approach should therefore adapt to patients at a particular point in time. For example, a patient who strives for abstinence often does not reach their intended goal in the short term. In these cases, controlled drinking can be a gateway to a life without alcohol and therapists should work with these patients to allow them to achieve their goal. Reinforcing abstinence can be counterproductive, as these patients can feel like ‘failures’ because they are still drinking, albeit in a much more responsible way.

The severely dependent drinker

Severe alcohol dependence is by far the biggest treatment challenge for any clinician and nearly all these cases will need to be referred by the GP for specialist care. It is associated with significant morbidity and mortality, and the outcomes tend to be far poorer than in patients with less severe forms of dependence. Except in rare cases, the severely dependent drinker will require hospital admission as their needs will be complex and they will require medically-assisted alcohol withdrawal to reduce the risk of withdrawal seizures and delirium tremens (DTs). About 5% of patients who experience alcohol withdrawal develop DTs ,which carries a mortality rate of 2-15%. 

In view of the potentially life-threatening complications of severe alcohol withdrawal, there needs to be a specialist, multidisciplinary and systematic approach to management. Many admissions with severe alcohol withdrawal will reach the emergency room before an addiction treatment facility and staff at these centres should be adequately trained to recognise the features of withdrawal. Elective admissions give the medical staff more time to plan management and are a more ideal way of treating severe alcohol dependence.

Managing severe alcohol dependence: key steps

• Having established severe alcohol dependence, with a high risk of DTs, a decision should be made to admit the patient to a specialist inpatient facility
• It is important that the assessment includes relevant medical and psychiatric history and any risk of suicidality
• Patients need to be kept under observation for any signs of unplanned withdrawal. The timing from the last alcoholic drink is crucial in this regard
• The role of pharmacotherapy needs to be established and individualised. Not all patients admitted to hospital will need medication
• Benzodiazepines are the mainstay of pharmacological treatment for acute alcohol withdrawal, usually oral chlordiazepoxide (Librium). The dose of medication should be symptom-triggered and individualised. It should take into account the level of alcohol dependence, the severity of withdrawal and evidence of co-morbidities, such as abnormal liver function
• The dose of chlordiazepoxide is reduced gradually over approximately five to seven days but may take longer, depending on the progress of withdrawal symptoms 
• The risk of DTs in the acute hospital setting is exceedingly low but in the event that the condition occurs, the dose of chlordiazepoxide will need to be adjusted and other drugs considered such as lorazepam, olanzapine or haloperidol to prevent further seizures and to control agitation. Long-term use of anticonvulsants is not indicated
• Wernicke’s encephalopathy (WE) should be considered in any patient presenting in a confused state with evidence of malnutrition. The other two classical signs that complete the triad are ophthalmoplegia and ataxia (although all three signs only appear together in one third of cases) 
• In patients with acute Wernicke’s encephalopathy, a significant number will develop Korsakoff’s psychosis or syndrome, which is characterised by disordered anterograde memory and other cognitive defects. The treatment of WE is with parenteral thiamine
• Thiamine should be given prophylactically in oral doses of 200mg daily to any patient with decompensated liver disease or who shows evidence of malnutrition.

Other pharmacotherapy

There are a number of drugs that have been used to treat alcohol dependence and an overview is provided here. Acamprosate (Campral) is an analogue of gamma amino-butyric acid (GABA). Its exact mode of action is unknown but it is thought to decrease alcohol consumption by reducing the positive reinforcement associated with alcohol consumption. Disulfiram (Antabuse) is an aversive drug that results in the accumulation of toxic acetaldehyde, by blocking  acetaldehyde dehydrogenase, when alcohol is consumed. Compliance can be a problem and the evidence suggests that the best outcomes are improved when a close family member or friend can supervise consumption of the drug. A recent therapy, the opioid antagonist nalmefene (Selincro) is indicated for the reduction of alcohol consumption in adult patients with alcohol dependence who have a high drinking risk level without physical withdrawal and who do not require immediate detoxification. It has EU approval and is going through the pricing/reimbursement process and is expected to be available in Ireland in 2014.

Follow-up and relapse prevention

Alcohol dependence comes with a high rate of reinstatement and relapse. Patients who become abstinent or drink within safe limits should maintain the positive changes in the long-term. The relapse prevention (RP) model developed by Marlatt and Gordon in 1985 is a cognitive behavioural approach to managing high-risk social situations that could be a trigger to lapse and relapse. There are two key features of this model in terms of relapse risk factors:

• Immediate determinants (eg. high-risk situations, a person’s coping skills, outcome expectancies and the abstinence violation effect) 
• Covert antecedents (eg. lifestyle imbalances and urges and cravings).

The RP model can be delivered in a variety of settings (including one-to-one sessions and group therapy) and can be very effective in maintaining long-term stability. There are a number of follow-up options for patients in recovery from alcohol dependence and each should be tailored to meet individual needs. These may be AA meetings or individual sessions with a counsellor, cognitive behavioural therapist, psychiatrist or GP specialising in drug and alcohol abuse. The number, intensity and frequency of sessions should be decided between the therapist and the patient.

Summary and conclusions

GPs are excellently positioned to screen patients and provide brief interventions for patients encountering alcohol problems. In the busy climate of general practice it is unlikely that most GPs have the resources and expertise to provide more intensive treatment.

Alcohol dependence is a chronic relapsing condition with a spectrum of severity. The treatment varies according to the extent of the disorder and the individual circumstances and health status of the patient. Relapse prevention therapy is an important tool to help patients maintain the positive changes and benefits of acute treatment.